Diverticulitis

Topic Overview

What is diverticulitis?

Diverticulosis happens when pouches (diverticula) form in the wall of the colon. If these pouches get inflamed or infected, it is called diverticulitis. Diverticulitis can be very painful.

What causes diverticulitis?

Doctors aren't sure
what causes diverticula in the colon (diverticulosis). But they think that a low-fiber diet may play a
role. Without fiber to add bulk to the stool, the colon has to work harder than
normal to push the stool forward. The pressure from this may cause pouches to
form in weak spots along the colon.

Doctors aren't sure what causes diverticulitis. Bacteria grow in the pouches, and this can lead to inflammation or infection.

What are the symptoms?

Symptoms of diverticulitis
may last from a few hours to a week or more. Symptoms include:

Belly pain, usually in the lower left side,
that is sometimes worse when you move. This is the most common
symptom.

Fever and chills.

Bloating and gas.

Diarrhea or constipation.

Nausea and sometimes
vomiting.

Not feeling like eating.

How is diverticulitis diagnosed?

Your doctor will
ask about your symptoms and will examine you. He or she may do tests to see if
you have an infection or to make sure that you don't have other problems. Tests
may include:

How is it treated?

The treatment you need depends
on how bad your symptoms are. You may need to
have only liquids at first, and then return to solid food when you start
feeling better. Your doctor will give you medicines for pain and antibiotics. Take the antibiotics as directed. Do not stop taking them just
because you feel better.

For mild cramps and belly pain:

Use a heating pad, set on low, on your belly.

Relax. For example, try meditation or slow, deep breathing in a
quiet room.

Take medicine, such as acetaminophen (Tylenol, for
example). Be safe with medicines. Read and follow all instructions on the label.

You may need surgery only if diverticulitis doesn't get
better with other treatment, or if you have problems such as long-lasting
(chronic) pain, a bowel obstruction, a
fistula, or a pocket of infection (abscess).

How can you prevent diverticulitis?

You may be
able to prevent diverticulitis if you drink plenty of water, get regular
exercise, and eat a high-fiber diet. A high-fiber diet includes whole grains,
fresh fruits, and vegetables.

Cause

Doctors aren't sure what causes diverticulitis. Bacteria grow in the pouches (diverticula), and this can lead to inflammation or infection. Pressure may lead to a small
perforation or tear in the wall of the intestine.
Peritonitis, an infection of the lining of the
abdominal wall, may develop if infection spills into the abdominal (peritoneal)
cavity.

The reason diverticula form in the wall of the large
intestine (colon) is not completely understood. Doctors think diverticula form
when high pressure inside the colon pushes against weak spots in the colon
wall. Uncoordinated movements of the colon can also contribute to the
development of diverticula.

Normally, a diet with adequate fiber
(also called roughage) produces stool that is bulky and can move easily through
the colon. If a diet is low in fiber, the colon must exert more pressure than
usual to move small, hard stool. A low-fiber diet also can increase the time
stool remains in the bowel. This adds to the high pressure. Pouches may form when
the high pressure pushes against weak spots in the colon where blood vessels
pass through the muscle layer of the bowel wall to supply blood to the inner
wall.

It is not known why some people who have these diverticula
(a condition called
diverticulosis) develop diverticulitis and others do
not.

Symptoms

Symptoms of
diverticulitis may last from a few hours to several
days. These symptoms may include:

Tenderness, cramps, or pain in the abdomen
(usually in the lower left side but may occur on the right) that is sometimes
worse when you move.

Fever and chills.

A bloated
feeling, abdominal swelling, or gas.

Diarrhea or
constipation.

Nausea and sometimes vomiting.

Loss of
appetite.

Complications also can cause symptoms. If an abnormal
opening (fistula) develops between the colon and the vagina or the colon and
the
urethra, you may pass air or stool from the vagina or
the urethra.

What Happens

Diverticulitis
occurs when pouches (diverticula) that have developed in the wall of the
large intestine (colon) become inflamed or infected. It is not clearly
understood why 20 out of 100 people who have these pouches—a condition called
diverticulosis—develop diverticulitis and the others
do not.

In Western countries (North America and Europe), diverticulitis usually affects the left side of the colon
(sigmoid colon).

Mild attacks of diverticulitis, with few symptoms
or signs of infection or inflammation, sometimes heal without treatment. In
most cases, a doctor recommends oral antibiotics to resolve an infection and a
clear liquid diet to rest the bowel until inflammation goes away.

When infection and symptoms are severe, diverticulitis is treated in the
hospital. Treatment includes antibiotics given in a vein
(intravenous, or IV) and resting the bowel with IV fluids. If severe
diverticulitis is not treated,
complications such as an
abscess or
fistula may develop. Surgery often is needed to treat
complications.

It is common to have lower abdominal pain after
recovering from an attack of diverticulitis. But this pain is not always a
return of diverticulitis. Less than half of people ever have a second
diverticulitis attack. Of those who do have another attack, about half have the
second attack within 1 year of their first one.1

When To Call a Doctor

Call 911 or other emergency services immediately if the person has been bleeding from the anus and
has signs of
shock, which could mean that a diverticular pouch
is bleeding (diverticular bleeding). Signs of shock include passing out, or feeling very dizzy, weak, or less alert.

Call your doctor immediately if you have pain in the abdomen
that is in one spot (as opposed to general pain in the abdomen), especially if
you also have:

Fever or chills.

Nausea and
vomiting.

Unusual changes in your bowel movements or abdominal
swelling.

Blood in your stool.

Pain that is worse when
you move.

Burning pain when you urinate.

Abnormal
vaginal discharge.

Call your doctor immediately if you
have:

Severe pain in the abdomen that is getting
worse.

Pain in the abdomen that becomes worse when you move or
cough.

A stool that is mostly blood (more than a few streaks of
blood on the stool). Blood in the stool may appear as reddish or maroon-colored
liquid or clots or may produce a black stool that looks like
tar.

Passed gas or stool from your
urethra while urinating. This likely means that you
have an opening (fistula) between the bowel and the urinary tract.

Call your doctor if you:

Have cramping pain that does not get better
when you have a bowel movement or pass gas.

Have rectal bleeding, a change in bowel habits, and you have been losing weight without trying.

Call your doctor if you are treating mild diverticulitis at home and:

You have a fever.

Your pain is getting worse.

You can't keep down liquids.

You are not better after 3 days.

Watchful waiting

It is not uncommon to have bloating, gas
pressure, or mild abdominal (belly) pain. These can be caused by eating certain foods
or by stress. Home treatment usually will take care of these symptoms. If home
treatment does not help or if the symptoms become worse, see your
doctor.

Who to see

Health professionals who can diagnose and prescribe treatment for
diverticulitis include:

Exams and Tests

Your doctor will
take a history and do a physical exam if
diverticulitis is suspected. Depending on your
symptoms, you may have one or more tests to rule out other medical problems
that could be causing your symptoms. The extent of testing will depend on how
bad your symptoms are and how long they have lasted.

Routine tests

These tests may be done any time
you see your doctor about abdominal pain or other symptoms.

Complete blood count (CBC) may show if
you have an infection or if you have too few red blood cells in your blood,
possibly because of bleeding in the colon.

Tests done as needed

Depending on your symptoms, your doctor may want to do one or more of
these tests.

A
computed tomography (CT) scan may be done if symptoms
suggest you have a pocket of infection (abscess) in your abdomen or that a
pouch (diverticulum) has burst. The scan also can reveal other possible causes
of your symptoms.

A
barium enema X-ray may be used to show
diverticula or other possible causes of your symptoms.
But a barium enema X-ray usually is not done while you are having an attack of
diverticulitis because of the risk that the barium might spill into the
peritoneum (the lining of the abdominal cavity) if you
have a perforation. A material that performs a function similar to barium but
that can dissolve in water (water-soluble contrast) may be used instead.

Flexible sigmoidoscopy and
colonoscopy may be used if your main symptom is
bleeding from the intestine. These tests also may be done to look for narrow
spots or growths in the intestine and to rule out
ulcerative colitis or cancer. But sigmoidoscopy and colonoscopy are not usually done while you are having an attack of
diverticulitis because of the risk that the scope could tear the lining of the colon (perforation). If this happens, the infection could spill into the
peritoneum (the lining of the abdominal cavity). This would cause a more serious infection.

Treatment Overview

You may have a brief (acute) bout
of
diverticulitis that goes away after treatment with antibiotics and a liquid diet. But in some cases the condition occurs off
and on (intermittently) over the long term (chronic). Treatment is the same in
both cases, unless complications occur.

Initial treatment

Treatment for
diverticulitis depends on how bad your
symptoms are. If the pain is mild, you are able to drink liquids, and you have no
signs of
complications, treatment may include:

Medicines such as antibiotics and pain
relievers.

Changes in diet, starting with a clear-liquid or bland
diet that is low in fiber until the pain goes away, then increasing the amount
of fiber.

If the pain is severe,
you are not able to drink liquids, or you have complications of diverticulitis,
a hospital stay is needed. Treatment will include:

Antibiotics given in a vein (intravenous,
or IV).

Intravenous fluids and nutrition only (no food or
drink by mouth) for up to a week to allow the bowel to
rest.

Treatment may also include:

Keeping the stomach empty by sucking out the contents through
a tube passed up the nose and down the throat into the stomach (nasogastric or
NG tube). This may be needed if you are vomiting or have abdominal
swelling.

Doing surgery either for complications of
diverticulitis or if you have had repeated attacks that are not helped by
changing your diet. Overall, fewer than 6 out of 100 people who have diverticulitis
need surgery.3

Most cases of promptly treated diverticulitis will
improve in 2 to 3 days. If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better.

Ongoing treatment

Treatment after recovery from an
attack of
diverticulitis is aimed at preventing another attack.
Treatment may include:

Gradually increasing the amount of fiber in
the diet through fruits, vegetables, wheat bran, and possibly the regular use
of a fiber supplement.

Getting plenty of fluids
daily.

Having regular doctor visits to monitor your condition. If
you have diverticulitis, the doctor may see you about 2 days after treatment
begins to make sure you are improving. A
colonoscopy or
barium enema X-ray probably will be done about 6 weeks
later, after symptoms are under control, to look for any other problems, such
as
inflammatory bowel disease or colon cancer.

Treatment if the condition gets worse

In some
cases,
complications of diverticulitis, such as an abscess,
perforation, or bowel obstruction, can occur.
Surgery to remove the affected part of the intestine usually is needed to treat
these conditions.

Nonurgent (elective) surgery also may be done
for diverticulitis if you have had two or more severe attacks, are younger than age 40, or have an impaired immune system.

Prevention

Some people avoid nuts, seeds, berries, and
popcorn, believing that these foods might get trapped in the diverticula and
cause pain. But there is no evidence that these foods cause
diverticulitis or make it worse.4

Home Treatment

Home treatment may help you control
symptoms of
diverticulitis or reduce the chance of having
additional attacks of diverticulitis.

To reduce abdominal pain
caused by mild diverticulitis:

Apply a heating pad to your abdomen to relieve
mild cramps and pain.

Try relaxation techniques (such as slow, deep
breathing in a quiet room or
meditation) to help reduce mild pain.

Use
a nonprescription pain medicine such as acetaminophen (for example,
Tylenol). Be safe with medicines. Read and follow all instructions on the label.

If these techniques do not help and your pain increases,
call your doctor to see whether prescription pain medicine is needed.

When you are feeling better, you can do some things to help
prevent another attack. You may want to:

Eat a
high-fiber diet. Whole-grain breads and cereals, brown
rice, and fresh fruits and vegetables can all be part of a high-fiber
diet.

Practice
healthy bowel habits, such as eating at regular times,
not straining during a bowel movement, and getting plenty of fluids each
day.

Do not use
laxatives or enemas unless your doctor prescribes them. If you use laxatives too often, you can become dependent on them for bowel movements. If you are having a sudden (acute) attack of diverticulitis, laxatives or enemas can make the pain worse.

Medications

Medicines to stop infection and to
control symptoms often are used to treat attacks of
diverticulitis.

Medicine choices

What to think about

Medicines are not used to
prevent future attacks of diverticulitis. Prevention depends on increasing the
amount of fiber in your diet and practicing healthy bowel habits.

Surgery

Surgery for
diverticulitis involves removing the diseased part of
the colon. You may decide to have surgery for diverticulitis if you
have:

Repeated attacks of diverticulitis. Surgery
to remove the diseased part of the colon often is recommended if you have two
or more severe attacks.

A high risk of repeated attacks (such as in people younger than age 40, or people with an impaired immune system).

An abnormal opening (fistula) that has formed between the
colon and an adjacent organ, most commonly the bladder, uterus, or
vagina.

Surgery for diverticulitis, in which the infected part of
the colon is removed, may be required if you have
complications, including:

An infected pouch (diverticulum) that has
ruptured into the abdominal cavity, especially if a pocket of infection (abscess) has formed. In some cases, an abscess can be
drained without surgery. (See Other Treatment.)

An infection that has spread into the abdominal cavity
(peritonitis).

A blocked colon (bowel
obstruction) or a narrow spot in
the colon (stricture).

Infection that has spread through the blood to other
parts of the body (sepsis).

Repeated problems with bleeding or severe bleeding that
does not stop with other treatments.

Overall, fewer than 6 out of 100 people who have diverticulitis
need surgery.3

Surgical treatment
involves removing the diseased part of the large intestine (partial colectomy)
and reconnecting the remaining parts. Depending on the severity and nature of
the symptoms, more than one surgery may be needed to correct the problem. When
multiple surgeries are needed, the person usually has a
colostomy during the time between surgeries. A
colostomy is a surgical procedure in which the upper part of the intestine is
sewn to an opening made in the skin of the abdomen. Stool passes out of the
body at this opening and into a disposable bag. Usually the colostomy is
removed at a later time and the intestine is reconnected.

Surgery choices

Surgical treatment of diverticulitis, called
bowel resection, involves the removal of the
diseased part of the large intestine.

What to think about

People who have mild, brief
attacks and who are willing to try long-term dietary changes may be able to
avoid surgery. See the Prevention section of this topic for more information on
diet.

If you have multiple attacks of diverticulitis, surgery may
be appropriate.

Other Treatment

Draining an abscess

In some cases of
diverticulitis, a pocket of infection (abscess) in the abdomen heals on its own. At other
times it can be drained without surgery. A needle is passed through the skin
into the abscess, and the liquid containing the infection is drained. A
computed tomography (CT) scan is used to help the
doctor guide the needle into the abscess. Sometimes a plastic drain is placed
temporarily in the abdomen to drain the abscess.

Bowel rest

A blocked colon can sometimes be treated with
bowel rest. You are not given anything to eat but instead receive fluids and
nutrients through a tube connected to a vein. Suction through a tube placed in
the nose and down into the stomach may be needed to keep the stomach emptied of
digestive juices.

After 2 to 3 days of bowel rest, you are given
something to eat. If the obstruction has cleared up, no surgery is needed. If
the obstruction remains, bowel rest may be continued. If repeated periods of
bowel rest fail to clear up the obstruction, surgery to remove the diseased
part of the colon may be considered.

Other Places To Get Help

Organizations

American College of
Gastroenterology

http://patients.gi.org

National Institute of Diabetes and Digestive and Kidney Diseases (U.S.)

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